by Carly Cotton
What first drew you to urogynaecology and pelvic floor surgery?
My early training was actually in anaesthesia and critical care. As Modernising Medical Careers came in, I found myself being asked to commit to that path for good — just as I was starting to want a different kind of challenge. I’d watched obstetricians and gynaecologists at work across theatres and the labour ward, and the specialty drew me in. Part of the appeal was its extraordinary breadth: it spans cancer, reproductive and maternal medicine, sexual health, fetal medicine, endocrinology and pelvic floor reconstruction, alongside some of the most profound ethical questions in medicine. Few specialties touch the lives of so many families so regularly. It is faintly ironic, then, that I went on to subspecialise so narrowly.
I’ve always been drawn to the practical, hands-on side of medicine, and urogynaecology is fundamentally about reconstruction and the restoration of function. It’s something of an unsung specialty, but one that can profoundly affect people living with the consequences of pelvic floor dysfunction. The right treatment can be genuinely life-changing.
Which developments in mesh complication management are most relevant to current litigation?
This is a relatively young field, and perhaps the most important development is our growing honesty about how much we still do not know. Long-term outcome data on mesh removal remains limited, and the specialist mesh centres established following the Cumberlege review are refining practice year by year rather than working from a settled evidence base. For anyone assessing these cases, that evolving and incomplete picture is itself a central fact.
A crucial point, often misunderstood, is that removal is not a straightforward remedy. Excision can be technically demanding and, in some cases, can create difficulties of its own rather than resolving them. The decision to remove, partially remove, or leave mesh in place is finely balanced and highly individual. There is also a significant psychological dimension that is easily overlooked: for some patients the knowledge that mesh has been removed carries real value, quite apart from the physical outcome. The field continues to work through complex questions about how symptoms, consent and patient wishes should shape management — and these are exactly the areas where careful, individualised assessment matters most.
What do you wish more solicitors understood about pelvic floor disorders and their impact on patients?
That the impact is so often far greater than the clinical labels suggest, and that much of it goes unspoken. These are conditions many women are deeply reluctant to talk about — problems with sex, and with urinary and faecal incontinence — and that reticence means the true burden is easily under-recognised. It reaches into self-esteem, relationships, work and mental health. My own research looked at body image after childbirth injury, and it consistently showed that the psychological consequences can be as significant as the physical ones.
For solicitors, the practical implication is that the real extent of harm is frequently not visible on the face of the records. Patient-reported outcome measures capture exactly this kind of information, yet in my experience they are not often sought, and can be absent from the notes bundles an expert is asked to work from. Understanding how a condition actually affects a particular person’s daily life often means looking beyond the operative notes — and asking the right questions.
How has your clinical leadership role shaped the way you assess standards of care?
Leading a service gives you a wider, more systemic view than clinical practice alone. You see the competing pressures a department operates under, and you come to understand how, under real-world constraints, care can fall short even where individuals are working conscientiously. The pandemic and the backlog recovery that followed placed enormous strain on services, and urogynaecology was particularly affected because so much of its work, while profoundly important to quality of life, is not classified as urgent. The result, in places, was suboptimal care on a scale driven by resources rather than individual failing.
That perspective makes me, I hope, a fairer assessor: it helps distinguish a genuine departure from the standard of care from the consequences of a system under pressure. But it cuts both ways. Understanding why something happened is not the same as excusing it, and the standard of care owed to an individual patient does not diminish simply because a service is stretched. Holding those two things together is central to assessing a case honestly.
What types of medico-legal cases are you most frequently instructed on?
My instructions reflect my clinical practice: complications following incontinence and prolapse surgery, mesh-related complications and removal, and the consequences of obstetric anal sphincter injury and perineal trauma sustained during childbirth. Consent is a recurring theme across all of these.
I accept instructions from both claimant and defendant solicitors, and I regard that balance as important. My duty as an expert is to the court, not to the party who instructs me, and taking work from both sides helps keep that duty at the centre of how I approach every case.
Which aspects of urogynaecology and pelvic floor surgery most often give rise to clinical negligence claims?
Broadly, claims tend to cluster around a few themes: whether a procedure was appropriately indicated in the first place, whether the patient was properly informed and consented, whether the surgery itself met the expected standard, and whether any complication was recognised and managed in good time. These are categories the court must weigh, not a checklist of failings — many claims turn on finely balanced clinical judgement rather than any clear departure from accepted practice.
What makes this specialty distinctive is that outcomes can be genuinely difficult to predict even when everything is done well, and complications can arise despite entirely appropriate care. Part of the expert’s role is to help the court distinguish between an adverse outcome and substandard treatment — which are not the same thing.
What can instructing solicitors expect from one of your medico-legal reports?
A report that is clear, proportionate and grounded in the contemporaneous records. I work from primary evidence first — the operative notes and the records made at the time — and check any secondary accounts against them, registering contradictions rather than glossing over them. Where the evidence supports a firm opinion, I say so; where it does not, I say that too, and explain why.
Because I both practise as a subspecialist and train and work alongside doctors with a special interest in urogynaecology, I am able to calibrate my assessment to the standard reasonably expected of the particular clinician and setting involved — which is often central to a fair view of the care given.
Solicitors can also expect strict discipline about scope. I keep condition and prognosis separate from breach and causation, and if an instruction appears to ask for one under the heading of another, I will raise it rather than blur the line. Above all, my overriding duty is to the court, and every report is written with that in mind.
What are the common issues you see in claims involving vaginal mesh complications?
At the case level, mesh claims tend to raise three recurring questions. The first is consent — what the patient was told about the use of mesh, the alternatives and the specific risks, and whether that discussion is reflected in the records. The second is the appropriateness of the original decision to use mesh at all, which has to be judged against the evidence base and guidance as they stood at the time, not as they stand today. The third is the recognition and management of any complication once it arose.
That point about timing matters a great deal. The evidence base and regulatory context around mesh have changed substantially over the past two decades, and a fair assessment has to place each decision in the context of when it was made. Judging a decision from the mid-2000s by the standards of today would not be a sound approach.
What factors are important when assessing whether pelvic floor surgery was appropriately advised and consented to?
The starting point is whether the surgery was appropriately indicated — whether a reasonable body of practice would have offered it to this patient at this time, having tried or considered the alternatives. An important and sometimes overlooked factor here is the place of conservative treatment. For many pelvic floor conditions, non-surgical options should be genuinely offered and given a fair trial before surgery is considered, and part of assessing whether surgery was appropriately advised is asking not only whether that option was mentioned, but how far the clinician went to ensure it was properly understood and tried.
From there, the question is whether the patient was given the information a reasonable person in their position would want, including the material risks and the realistic alternatives, so that the decision was genuinely theirs. Since Montgomery, the emphasis is firmly on that individualised discussion rather than a one-size-fits-all disclosure. Assessing consent therefore means looking not just at what was offered, but at how the decision was reached and whether the patient was properly placed to make it.
How do you assess cases involving alleged failure to diagnose or manage obstetric pelvic floor trauma?
I run a dedicated perineal clinic alongside colleagues in the St Mary’s urogynaecology team, and my doctoral research some years ago was in severe perineal trauma following childbirth. It is worth saying at the outset that this work spans considerably more than anal sphincter injury: a good deal of the clinical and medico-legal caseload concerns perineal trauma and its consequences more broadly — chronic pain, dyspareunia, problematic scarring and poor healing among them — where the anal sphincter may be entirely intact.
Where a sphincter injury is alleged to have been missed, an important distinction has to be drawn. If a tear extends to the sphincter muscle, the duty is to recognise it clinically at the point of injury. That can be genuinely difficult in the conditions of delivery, but difficulty does not remove the duty: the expected standard is careful examination and, where there is any doubt, examination under anaesthesia and classification to the higher category rather than the lower. That is different from a true occult injury — a defect seen in the muscle on later ultrasound where the tissue was never torn through to that level. By definition there is no clinical tear to find at the time, so such a defect cannot be diagnosed on examination however diligent the clinician, and its clinical significance remains a matter of debate. Conflating the two is a common error.
The most finely balanced cases, in my experience, are those where a tear was properly recognised and repaired but subsequently broke down. Distinguishing a repair that was inadequate from the outset from a recognised complication of a technically sound repair is rarely possible from any single entry in the records; it is the post-operative trajectory, read as a whole, that tells the story. And throughout, recognition, classification and repair must be judged against the training standards and guidance in force at the time, not against current expectations.
What issues commonly arise in claims involving stress urinary incontinence surgery or prolapse repair?
Alongside consent, these claims frequently concern whether the chosen procedure was appropriate for the individual, the technical conduct of the operation, and the recognition of complications such as injury to adjacent structures, voiding difficulty, or recurrence. Recurrence in particular is often misunderstood: prolapse and incontinence surgery do not carry a guarantee of permanence, and a recurrence is not in itself a sign that anything was done wrongly.
The landscape has also shifted considerably. The pause on the use of surgical mesh changed the range of procedures a surgeon could reasonably offer, and brought a renewed emphasis on appropriate training, counselling and consent. The options available, and the expectations around how they are discussed, therefore have to be considered in their proper timeframe. As with much of this work, the central task is to separate a disappointing outcome from a departure from acceptable practice.
How important is informed consent in urogynaecology claims, and what should solicitors look for in the records?
Consent is central — it is one of the issues on which these claims most often turn. But a signed consent form is not, on its own, evidence of a proper consent process. What matters is the quality of the discussion behind it, and consent is best understood as a process rather than a single moment.
In the records, I would encourage solicitors to look for evidence of a genuine dialogue: that the specific risks and the realistic alternatives were discussed, that the patient’s own concerns and circumstances were taken into account, and that there was adequate time in the period before the decision for it to be a considered one, rather than a conversation immediately before surgery. Clinic letters, the surgeon’s own notes and any patient information provided often tell the real story more faithfully than the consent form itself. Where that documentary trail is thin, that in itself is a material finding.